Photo Quiz

June 3, 2007
Michael P. Phelan, MD, The Cleveland Clinic Foundation, Department of Emergency Medicine, Cleveland, Ohio

Internal Medicine World Report, February 2006, Volume 0, Issue 0

The Cleveland Clinic Foundation, Department of Emergency Medicine, Cleveland, Ohio

A 60-year-old woman presented to the emergency department with a change in mental status. Her medical history included hypertension, cerebrovascular accident, chronic atrial fibrillation, and chronic use of warfarin (Coumadin). Her family found her slumped over and unable to communicate. She was intermittently responding to questions and commands but did not respond to visual threat. Her pupils were equal and reactive. A computed tomography (CT) scout film (Figure 1) and noncontrast CT scans of the head (Figure 2) provided clues to the diagnosis.

Photo Quiz Answer

Pituitary apoplexy. The noncontrast CT of the head shows a region of high attenuation in the sella turcica, with a focal hyperdense mass arising from the sella. Of note, on the CT scout film the sella is enlarged and effaced, consistent with an eroded sella. The medical ­history and the CT scans are consistent with pituitary apoplexy, a term coined by Brougham and colleagues in 1950 to describe a constellation of ­acute clinical symptoms—headache, visual disturbance, ophthalmoplegia, and altered level of consciousness. This ­constellation of symptoms occurs primarily in patients with pituitary adenomas that have enlarged and hemorrhaged. This patient’s noncontrast head CT scans are consistent with a hemorrhage into the pituitary. Urgent neurosurgical consultation was obtain­ed, and the patient underwent transspheno­idal adenomectomy and removal of in­farcted pituitary. Her confusion resolved, and her vision improved, postoperatively.